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FACILITY INFORMATION <br /> Business Name: <br /> Owner/Operator Name: <br /> Street Address: <br /> City: Zip Code: <br /> Mailing Address: <br /> Phone Number: <br /> APPLICANT/CONTRACTOR <br /> Name: <br /> Street Address: <br /> City: Zip Code: <br /> Phone Number: <br /> Contractor's License Number: Class <br /> Certificate of Worker's Compensation Insurance on file with PHS/EHD? YES NO <br /> UST SYSTEM BLUEPRINT INFORMATION <br /> 1. Four complete sets of plans (specification sheets and/or equipment <br /> br hures if not on file). <br /> 2. ans drawn to scale in non-erasable blue print. <br /> 3. Plot plan to show location and number of tanks. <br /> 3 <br />